Lessons to Be Learned in Storm's Aftermath

No one on the East Coast was totally prepared for the devastation unleashed by Hurricane Sandy last fall, but, on Staten Island, they really got blindsided. Fortunately, one local family doctor realized that widespread flooding, massive power failures and overwhelming structural damage would put his patients and his community at risk for serious health problems, and he hit the ground running.

The immense storm surge from Sandy hit New York and New Jersey on Oct. 29, flooding streets, tunnels and subway lines in major cities, as well as cutting power up and down the eastern seaboard. To date, losses due to damage and business interruption are estimated at $65.6 billion, which ranks Sandy right behind Katrina as the second-costliest Atlantic hurricane on record.

Although the storm eventually affected nearly half of the United States in some way, Staten Island -- an extremely low-lying New York City borough -- was particularly hard hit, according to family physician Neil Nepola, M.D., who lives there.

"When the storm occurred, no one expected it to be the magnitude it was," Nepola told AAFP News Now. "Although the weather reports stated it was going to be severe, no one really felt that the impact was going to be as great as it was."

According to Nepola, who is a past president of the New York State Academy of Family Physicians (NYSAFP), the fact that Staten Island had weathered so many big storms in the past likely gave residents a false sense of security. And even though the local authorities had worked to prepare the island's storm sewers and had even raised one of the major roadways to prevent water from traversing into the lowest-lying areas on the island, it wasn't enough.

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Hurricane Sandy hit the East Coast in late October 2012, causing an estimated $65.6 billion in damage and lost business.

The New York City borough of Staten Island was particularly hard hit.

A local family physician helped to create the Staten Island Medical Corps, a coalition of volunteers and community organizations that provided care to victims of the storm via three buses converted into mobile clinics.

The water rolled inland in some places as much as a mile from the normal high water mark, according to Nepola. "All the electricity on Staten Island pretty much went out, save maybe 20 percent of the houses, leaving the entire East Shore and South Shore completely dark," he said.

Filling a Need

Nepola said he was overwhelmed by what he saw the day after the storm.

"I quickly realized that a lot of neighborhoods were completely underwater," he said. "One-story-tall houses were completely submerged or knocked off their cinderblock foundations … some actually shifted hundreds of feet away from their foundations.

"Cars and boats were brought up from the water and shifted hundreds of yards or more. There were boats from the marina that were found eight to10 blocks away from where they were originally docked."

Nepola said it quickly became apparent that although officials at the Federal Emergency Management Agency's (FEMA's) Disaster Recovery Center on the island were doing their best -- giving out water, food, clothing and blankets -- they had no plan in place to care for the medical needs of the population.

Soldiers from the National Guard load one of the three buses the Staten Island Medical Corps used as mobile clinics.

"The Office of Emergency Management was in charge of the medical outreach, but they didn't really have any organization prepared to handle the medical care that I saw was going to be necessary," Nepola said. So, he teamed up with another physician and a nurse practitioner (NP) to create the Staten Island Medical Corps(www.facebook.com) (SIMC). Together, the three recruited a group of doctors, nurses, nurses aides, physician assistants, NPs and ambulance drivers.

"Anybody who was willing to volunteer, we were willing to accept," Nepola explained.

The group also approached Staten Island University Hospital and got the go-ahead to start gathering vaccines and materials to treat minor wounds. Subsequently, they acquired three buses outfitted with exam rooms that were deployed in major areas of destruction on the island. The team then went door-to-door in a grid-like pattern with the following game plan:

treat acute illnesses;

bridge the prescription gap between patients and pharmacies;

give vaccinations; and

align people with social agencies that could provide them with housing, as well as those that could offer them counseling for psychosocial issues.

Disaster Management Plan Can Protect Vaccines

Family physician Margot Savoy, M.D., M.P.H., medical director of family medicine centers and youth rehabilitative services for the Christiana Care Health System in Wilmington, Del., took advantage of a newly installed disaster planning system to safely move vaccine supplies before Hurricane Sandy made landfall.

"We had a major power failure about a month before the hurricane, and, in our debriefing, we realized we should streamline that particular portion of our disaster management plan," she told AAFP News Now. "When the hurricane came along, our updated plan went smoothly and was much less stressful for everyone involved. I was super proud of my staff for knowing what to do and getting it done quickly and efficiently."

Savoy said every practice should have an up-to-date disaster or emergency plan that encompasses a number of important components.

Maintain a list of key contacts for all areas of the office. Knowing exactly who to call for all the parts of the office that may be affected is extremely helpful, according to Savoy. "It makes it easier to delegate when you have all the information in one central location," she said.

Ensure that contact information for staff and health care professionals is complete and up-to-date. Cell phone numbers should be on record in the event home phone lines are down.

After the event, consider alternatives to phone trees or patient cancellation calls. A number of services (e.g., Phonevite, Televox) make it possible to rapidly call a large number of people with a prerecorded message at a reasonable price.

Consider flexible scheduling and/or a walk-in day after the event instead of rescheduling all the visits. "We caught up cancelled patients quickly by opening schedules and allowing same-day/walk-in (appointments) to make up visits," said Savoy.

Savoy also offered recommendations on how to safeguard vaccines and other refrigerated perishables in the event of an emergency.

"Check with your hospital pharmacy; they may allow you to store vaccine properly labeled and packaged for the emergency," she advised. Alternately, some companies will do this for a fee. In emergent situations, your department of health or a local retail pharmacy also may be able to assist you.

"Make sure you have a stock of frozen ice packs and Styrofoam packing crates on hand so you can pack quickly," Savoy advised. "Also, if you leave the defrosted (ice packs) in the freezers when you leave, when the power comes back on, they will be already frozen for your return packing trip."

Vaccines for Children stock should be separated from private-pay vaccines to avoid restocking headaches. It's also a good idea to separate frozen vaccines from refrigerated ones when packing.

Label the vaccine containers with your practice name and contact information, and log what you take to the external site and what you get back.

Consider purchasing a freezer alarm that can notify you if there is a problem with your storage system. "Some can call you if there is an issue with the temperature change before there is any loss of vaccine," said Savoy.

Don't forget your controls or other perishable testing kits. "In our office we had to take over our hemoglobin A1c testing supplies in addition to the vaccine and tuberculin supplies," Savoy noted.

Finally, work ahead if at all possible, said Savoy.

"It was so much easier for us to take care of our vaccines on Sunday afternoon when we knew the storm was coming," she said. "We could take our time, double check and get everything where it needed to be with minimal stress.

"Also, volunteers to help pack and carry are much easier to recruit before trees start flying."

"Many of these patients had no way of replacing their medications and prescriptions, so we provided medications and the service for them to get the prescriptions," said Nepola. "We also ran into workers who were helping to clean out the houses and gave those workers tetanus vaccines and flu vaccines."

Residents also could get treatment for some of the mental health and social service issues that were arising at the mobile clinics, according to Nepola.

"A lot of people -- 22 or 23 -- had died as a result of the storm, and because these neighborhoods are so close-knit, everyone knew these people," said Nepola. "So we did a lot of counseling, a lot of education."

Between SIMC and the other charitable organizations out serving the community, Nepola estimated that 800-1,000 homes were visited.

Going Forward

Nepola said he hopes Staten Island's government and the other agencies that responded to Sandy take note of what SIMC accomplished and address the lack of organized medical outreach.

"There was no health czar to control all the various organizations that were trying to organize health care delivery, but now we've organized that," he said. By making contact with the medical clinics at Staten Island University Hospital and a nearby federally qualified health center, the group was able to provide immediate clinical evaluation and treatment for patients who had lost contact with their health care professional or who had received no medical care in the past.

"I believe there should be a medical arm that can control and advise volunteers as to what steps can be taken in order to provide care," said Nepola. "From a community readiness point-of-view, I think it would be a good idea to assess the doctors and the nurses who worked with us on this occasion and try to recruit more volunteers in advance so that we will be organized if and when another disaster occurs."

Lessons From Others Affected

According to NYSAFP President-elect Raymond Ebarb, M.D., of West Sayville, communities such as Staten Island also would do well to develop a system similar to the Joint Emergency Evacuation Program (JEEP) and Special Needs Registry(www.suffolkcountyny.gov) used by the Suffolk County (N.Y.) Office of Emergency Management (OEM). JEEP provides shelter and transportation assistance to individuals with special needs who have no way to evacuate their homes during a disaster.

"People in my community simply have to fill out the form on the JEEP website and send it in, and the people from the OEM will come looking for them in the event of a disaster," said Ebarb.

That's important, said Nepola, because the storm taught organizers that people don't want to leave their immediate neighborhood after a disaster.

"People did not want to go miles away from their homes because they were afraid something would happen while they were gone," he said. "I don't think people knew that before this happened, but it makes perfect sense to me now. People wanted to stay put, so we went to them."

As for how Nepola plans to better prepare his own office in the event of an impending storm, he said letting his patients know how to contact him in the event the power goes out, as well as addressing any prescription or medical needs that could be an issue, would be top priorities.

"My office wasn't that affected other than the electricity going out for five days and all of my vaccines being lost," he said. "So, next time, I'd like to have a plan in place to transport all the vaccines and other perishables to a generator-supported refrigerator, if at all possible."

For his part, Ebarb said his staff developed a texting system to be used in the event of an emergency. That foresight set them in good stead when Sandy struck.

"Even though we still had lights, the roads were not clear, so a lot of staff were not able to make it in," Ebarb said. "And, in a lot of cases, you cannot call people, so texting works well in terms of communicating with both staff and our patients. Our office manager takes care of coordinating that.

"It's also important to be in touch with the local hospital," he added. "Even if your office is closed down, you and the rest of the doctors in your practice may be in a position to help at the hospital, and they need to be able to get in touch with you."

Richard Corson, M.D., of Hillsborough, N.J., a past president of the New Jersey Academy of Family Physicians, said mobile phones also became a mainstay in his area after the storm hit, allowing significant coordination by the area hospital, which opened up facilities for physicians who had lost power in their clinics.

Equally important, said Corson, was knowing that his electronic medical record (EMR) system would preserve every patient record in his small practice.

"I went digital in 2007, and the EMR system I have backs up everything in a server housed a few miles away from the AAFP offices in Kansas City," Corson said. "So even though we lost power here, I wasn't worried about health records because they are all in the cloud.

"And, because I had my cell phone, I was able to access all of the information wirelessly, which meant I could answer questions and run my practice even though we didn't have a working office."